Ameritox

Urine Drug Monitoring Guidelines

An emerging consensus among many professional organizations, as well as state guidelines, recommend routine and random urine drug monitoring as a part of treating patients on chronic opioid therapy (COT).

Below is an overview of published clinical guidelines supporting routine urine drug monitoring of patients on chronic opioid therapy.

Periodic & random drug monitoring

Treatment agreements should include drug monitoring

Drug monitoring prior to the initiation of opioid therapy

Drug monitoring should be based on risk stratification

2012 Expert Consensus Recommendations2

American Pain Society/American Academy of Pain Medicine3

American Society of Interventional Pain Physicians4

Department of Veterans Affairs – Department of Defense5

American College of Occupational and Environmental Medicine6

 

2012 Expert Consensus Recommendations2
  • Recommendations can be found at: www.ameritox.com/recommendations
  • 2012 Consensus recommendations help answer five key areas faced by clinicians, including: 1. Whom to test; 2. How to test; 3. When to test; 4. How to interpret results; 5. How to handle discrepancies in test results
  • Recommends all patients who are prescribed opioids for long-term pain management should undergo comprehensive urine drug testing, and  a “complete history and physical, appropriate psychological screens, and other evaluations.”
  • Patients should be monitored based on risk stratification. Patients evaluated as low risk should be monitored a minimum of twice per year. Patients evaluated as moderate to high risk should be monitored a minimum of four times per year.
  • Practitioners should be aware of state requirements and regulations that pertain to monitoring.
  • Each patient is unique, and a great deal of clinical judgment is required to handle discrepancies in patient’s urine drug testing results. For ALL Unexpected Findings: verify results with the lab; document findings and schedule a follow-up visit with the patient; meet with the patient and discuss findings in a non-judgmental open-ended manner; Review treatment agreement, counsel as necessary, and consider repeated or additional testing. Additional recommendations as to how to handle specific results can be found in the full recommendations.
  • Download a copy of the 2012 consensus recommendations in full: www.ameritox.com/recommendations
American Pain Society/American Academy of Pain Medicine3
  • Guidelines can be found at: http://www.jpain.org/article/S1526-5900(08)00831-6/fulltext
  • “In patients on chronic opioid therapy (COT) who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information” as part of their plan of care.”
  • “In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information” as part of their plan of care.”
  • Regular monitoring of patients “critical because therapeutic risks and benefits do not remain static and can be affected by changes in the underlying pain condition, presence of coexisting disease, or changes in psychological or social circumstances.”
American Society of Interventional Pain Physicians4
  • 2008 Guidelines can be found at: http://www.painphysicianjournal.com/2008/march/2008;11;S5-S62.pdf | 2012 Guidelines can be found at: http://painphysicianjournal.com/2012/july/2012;%2015;S67-S116.pdf
  • “Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. “(2012)
  • Physicians should use a screening tool to assess patient risk and monitor patients at different intervals based on risk stratification. (2012)
  • Recommends urine as the preferred method of testing (over serum or hair), noting it is the “best biologic specimen for detecting the presence or absence of certain drugs due to specificity, sensitivity, ease of administration and the cost”
  • Says it is “extremely important” to regularly assess the patient and to review the diagnosis, noting that “routine assessment of the “4 As” (analgesia, activity, aberrant behavior and adverse effects) will help to direct therapy and support pharmacologic actions taken.”
  • Urine drug testing “should be random, well organized, and synchronized with a well-understood testing lab”
Department of Veterans Affairs – Department of Defense5
  • Guidelines can be found at:  http://www.healthquality.va.gov/Chronic_Opioid_Therapy_COT.asp
  • Patients should be informed that urine drug testing is “a routine procedure for all patients starting on opioid therapy, and is an important tool for monitoring the safety of their treatment.”
  • Drug monitoring should begin prior to starting a treatment regimen.
  • Increasing the frequency of UDT should be based on risk.
  • In order to make clinical decisions, a clinician should take into account other information (risk factors, aberrant behaviors, etc.) when interpreting results.
  • In order for a clinician to be able to accurately interpret results, the clinician should understand laboratory methods and reporting. They should “maintain a close working relationship with the clinical laboratory to answer any questions about the UDT or for confirming the results.”
American College of Occupational and Environmental Medicine6
  • Guidelines can be found at:http://www.acoem.org/Guidelines_Opioids.aspx
  • Routine urine drug screens for patients on chronic opioid therapy is recommended.
  • Recommended initial test of patient prior to treatment.
  • Random monitoring should occur at “at least twice and up to 4 times a year and at termination.”
  • Urine drug screening should be performed in scenarios where a provider may suspect misuse or abuse.
CITATIONS

1-       Hughes, M.A. et. al. (2012) Recommended Opioid Prescribing Practices for Use in Chronic Non-Malignant Pain: A Systematic Review of Treatment Guidelines. Journal of Managed Care Medicine . 14(3) 52-58.

2-       Peppin, J.F. et al. (2012) Recommendations for Urine Drug Monitoring as a Component of Opioid Therapy in the Treatment of Chronic Pain. Pain Medicine, 13 (7), 886-896.

3-       Chou R., Fanciullo G.J., et al. (2009) Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain 10(2):113-130.

4-       Trescot A.M., Helm S., Hansen H., Benyamin R., Glaser S.E., Adlaka R., Patel S, Manchikanti L. (2008) Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians’ (ASIPP) guidelines. Pain Physician. 11(2S) S5-62.

5-       Department of Veterans Affairs, Department of Defense. (2010) The Management of Opioid Therapy for Chronic Pain Working Group, VA/DoD Clinical Practice Guideline, Management of Opioid Therapy for Chronic Pain. Washington, DC. Retrieved On November 1, 2012 from: http://www.healthquality.va.gov/Chronic_Opioid_Therapy_COT .asp.

6-       Hegmann, K.T. & Glass, L.S. (Ed.) (2008) Occupational Medicine Practice Guidelines, 2nd Edition. American College of Occupational and Environmental Medicine (ACOEM)